70th AHCA/NCAL Convention and Expo
To achieve the triple aim of health care—improved patient experience, better health of populations, and reduced per capita cost—effective case management for transitions within and between settings is critical. That requires tight integration of clinical services, patient/family engagement, and continuous coordination among the interprofessional team. This presentation will outline essential elements and illustrate replicable case management best practices that support successful care transitions.
We will detail three best practice standards that our organization implemented: establish an operational interprofessional team; assess risk for rehospitalization and implementing a tailored care plan based on risk profile; and conduct a post-admission patient/family conference within 72 hours of admission.
We will illustrate the importance of case management across care settings through organizational examples, including a skilled nursing/home health partnership best practice demonstration project, and a post-discharge follow-up program involving a team of nurses and social workers for targeted centers.